USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 37
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18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
In the
ds.
State
yrs.
mos. .
ds ..
...
Where was disease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
July 13! 1911.
ADDRESS
Filed. 191.
REGISTRAR
BOSTON .....
(City or town.)
'FULL NAME Monta G. Ungalle
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Haderer
1830
(Year)
If LESS than I day, .... ... hrs.
or ....... min. ?
12 MAIDEN NAME OF MOTHER Lydia Sowill
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
1 PLACE OF DEATH [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 3 SEX 4 COLOR OR RACE 6 DATE OF BIRTH (Month) (Day) 7 AGE 8 OCCUPATION (a)' Trade, profession, or particular kind of work ... (b) General nature of industry, business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country> 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) PARENTS 13 BIRTHPLACE OF MOTHER (State or country) (Informant) important. See instructions on back of certificate. (Address) 15 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 81 yrs. 2. mos. 16 .ds.
Huntrofe mass.
, M.D.
20 UNDERTAKER
E. G. BROWN & SON,
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: («) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Vone.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of .. .. (name origin : "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gus Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
1
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
Whichit
-BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Charles Pentland G Cack 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 60 Enligt Core
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Make
4 COLOR OR RACE
tutute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Lunga
6 DATE OF BIRTH
March
27
(Month)
(Day)
(Year)
7 AGE
54
yrs.
4
mos.
ds.
or ..
... min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
telek
(b) General nature of industry,
business, or establishment in
which employed (or employer)
sail Mig, 00
9 BIRTHPLACE
(State or country)
Wheeling Va
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Wheeling Va
12 MAIDEN NAME OF MOTHER Julia Evans
13 BIRTHPLACE OF MOTHER (State or country)
alexandra va
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
que. Calma En
(Address)
Goblin are wiechert
16
Filed. 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
11.
(Day)
1912.
(Year)
17
i HEREBY CERTIFY that i attended deceased from
Jecky 11th
, 191.L., to
191
that IMast saw hauw alive on
191
and that death occurred, on the date stated above, at
JEX m.
The CAUSE OF DEATH* was as follows :
(Duration)
2
.yrs.
mos.
ds.
Contributory (SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
M.D.
(Address) thanspeed
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18/LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
State.
yrs.
In the
.mos.
... ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
July 14
20 UNDERTAKER
ADDRESS
whicho
--
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No ...
60 eux ave
St. :
Ward)
1
10 NAME OF
FATHER
William Bedford Clark
If LESS than
I day ..... ... hrs.
1957
0 8
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be kuown. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kiud of work and also (b) the nature of the business or industry, and thereforo an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Nover return "Laborer," " Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. -- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. .. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (sccond- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " AI- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertaincd as tlie cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under tho following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc. .
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Maria
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
(No. 410 Shirley Rollins Widow of
St. :
Ward)
L. Rollno Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX female
4 COLOR OR RACE Mute
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word)
urea.
[6 DATE OF BIRTH
6
(Month)
(Day)
(Year)
7 AGE
78
.. yrs.
mos.
...
ds.
8 OCCUPATION
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Boston- Mas
PARENTS
11 BIRTHPLACE OF FATHER (State or country) intern
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed. 191 ..
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
13
(Day)
191 /
(Year)
12
I HEREBY CERTIFY that I attended deceased from
31
Day 13
1911.
1911
to
If LESS than I day, hrs. that I last saw h alive on 191.L., or ..... min. ? and that death occurred, on the date stated above, at & ~ Pm. The CAUSE OF DEATH* was as follows :
Diabilis Welliton
execution yester mos. .. ds.
Contributory
Chain Valvula Heart and ch.
Redning desen you
mos.
ds.
(Signed)
Jeg14, 1911 (Address)
M.D.
*If death followed injury or violence the certificate of death must be made but by me Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ..
yrs.
mos.
In the
ds.
State ..
... yrs.
mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Glenwood Surely
DATE OF BURIAL
Jul 15
1
191
.......
CO UNDERTAKER
ADDRESS
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
BOSTON
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
10 NAME OF FATHER inveruno
July 15, 1111
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to eacli and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who aro engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Hlousewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never rc- port " Typhoid pneumonia ") ; Lobar pneumonia, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) : Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. .. (name origin: "Cancer" is less definite ; avoid use of "Tumor " for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mero symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapsc," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy,""Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found deud, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 77
Bartlett Rous.
0
(City or town.)
Ward)
Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED ned
(Write the word)
6 DATE OF BIRTH
6 (Month)
9
1854
17
(Year)
7 AGE
If LESS than day, hrs.
57 yrs.
/ mot.
4ds.
or min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work. House Wife
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Holliston Mass.
10 NAME OF
FATHER
Porphy Hawes.
PARENTS
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Bang. L. Cally
(Address)
16
Filed. 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(
13 8
/
(Month)
(Day)
, 19! (Year)
to
I HEREBY CERTIFY that h attended deceased from
5
, 191
3. 191/.
that I last saw h Er
alive on
1 5 . 191 % .
and that death occurred, on the date stated above, at. /. m.
L
The CAUSE OF DEATH* was as follows :
...
7
.(Duration)
yrs.
mos.
ds.
Contributory.
(SECONDARY)
(Duration)
yrs. .
mos. . .. ds.
(Signed)
7,14
, 191 /
(Address)
Chilam Ilien,
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
State
In the
yrs.
mos.
ds.
Where was disease contracted, if not at place of death ? ..
Former or usuai residence.
19 PLACE OF BURIAL OR REMOVAL Brood Lawn
DATE OF BURIAL
July /6, 1911
ADDRESS
20 UNDERTAKER
9h. C. ka yar
2 FULL NAME.
Eva & Cally.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 77 Bartlett Road.
Buy Fi Cally. ()
(Day)
11 BIRTHPLACE OF FATHER (State or country)
.. M.D.
STANDARD CERTIFICATE OF DEATH,
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborcr, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fevcr (the only definite synonyın is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of " Tumor " for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be state? unless im- portant. Example: Measles (disease causing deatlı), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy,'' "Collapse," "Como," "Convulsions," "Debility " ("("ongenital,"
"Senile," etc.), "Dropsy," "Exhaustion," " Heart failure," "Haemorrhage," " Inanition," " Marasmu"," " Old age," "Shock," "Uraemia," "Weakness," etc. when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to bc due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Itwithrowe .
.(No. 72 Boudou St. ;...
Maria Baker. 2 FULL NAME
{ If married er divorced woman.or widow give maiden name, also name of husband.] @RESIDENCE
Henry D. Bake
(City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Undorcad
6 DATE OF BIRTH
6 (Month)
5
1837
17
(Day)
.,
(Year) )
7 AGE
If LESS than 1 day, . hrs.
80 yrs. / mot ds, 7, or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
at home.
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Pembrook mass.
10 NAME OF
FATHER
Edward Drake.
PARENTS
12 MAIDEN NAME OF MOTHER
Thang Coy
13 BIRTHPLACE OF MOTHER (State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
author 1Pakel
(Address)
171 Dehauling st-
15
Filed 191
REGISTRAR
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